Casework Satisfaction Survey | U.S. Representative John Curtis

Contact Information

First Name: *

Last Name: *

Email Address: *

Street Address: *

Street Address: (Continued)

City: *

State: *

Zip Code: *

Phone Number: *

Organization Name: *

Overall Satisfaction of Service

How would you rate the professional manner of our service?:
5 - Excellent
4 - Above Average
3 - Average
2 - Below Average
1 - Poor

How would you rate our communication with you?:
5 - Excellent
4 - Above Average
3 - Average
2 - Below Average
1 - Poor

Do you have any other feedback you would like to leave our office?:

Newsletter

Would you be willing to allow us to include your casework story in one of our office's monthly newsletters?: *
Yes, I consent to the Office of Congressman Curtis releasing my story with my first name
Yes, I consent to the release of my story, but please do not include my name or identifying details
No, I do not consent to the release of my story in any form

Please describe your experience below:

If you choose, please upload a photo of yourself to be included in our newsletter:

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Macintosh users: Your document must have a file extension. Resave it using your word processor with the appropriate extension from the above list.

Would you like to be included on our mailing list?:
Yes
No